Joint health initiative to help long-term sick in Barking and Dagenham

A GP has spoken of an ambitious new project in Barking and Dagenham that sees staff at GP practices, hospitals, the council, and other local organisations come together to improve the care of people suffering from long-term conditions.

Dr Jagen John, of King Edward’s Medical Centre, in Barking, is one of a number of north-east London GPs who is leading the programme, which has recently spread to Waltham Forest and Redbridge.

Every fortnight a team made up of a GP, community matron, district nurse, social worker and a care co-ordinator meets at every GP surgery in the borough to discuss and agree holistic care plans for patients with long-term health problems. Sometimes they will be joined by other health professionals and staff from voluntary sector organisations such as drug and alcohol support groups.

Dr John said the integrated care project, which was launched in the borough around 12 months ago, aims to cut through red tape and improve communication between the different bodies who encounter the patients.

“Before we started the programme we filmed patients with long-term conditions talking about their experiences and we found out that there were often gaps in their care,” Dr Jagen told the Post. “This we believe was down to a lack of communication between the different services.

“By coming together and talking to one another we can make sure their care is far more consistent, which in turn should cut the number of times patients are admitted to hospital.”

The care co-ordinators, he said, are vital to the whole programme.

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He explained: “They are the ones who will help patients navigate various services, educating them on who to contact in a crisis and update care plans so the GP can get an up-to-the-minute picture of who a patient is due to see next.”


He said early results of the project have been encouraging, with patients saying they are now able to access social care more quickly.

He added: “There is also a reduction in home visits as patients feel more supported. Hospital admissions by Barking and Dagenham residents have fallen slightly, as have the length of stay of those who do go to hospitals, In a borough which has a high proportion of people with health problems this is great news.”

Dr Jagen explained that the model was a work in progress and the GPs leading it would continue listening to patients and changing their approach if needed.